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veloso

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Can I pull elements from the ASSESMENT/TREATMENT in order to have 4 bullets for the HPI for level 4 (99214)?


HPI:
Pt. has c/o pain to rt wrist which is new ... he's had the pain off/on x's past "few wks" . (HOW MANY ELEMENTS I HAVE FOR THIS PARTICULAR HPI)???

ASSESSMENT/TREATMENT:
Injury of elbow, forearm and wrist
Wrist pain started when he was working out with heavy weights (60-70 lb weights) ... the pain persisted despite 2 months off gym ... I have referred James to PACC @ BIMC to rehab docs ...


Thanks a lot ,again.
 
There are three HPI elements in that statement:

Location - Wrist
Duration - past few weeks
Quality - off and on

As far as taking the fourth element from the Assessment, Highmark Medicare Services advises that the HPI can be obtained from anyplace in the note. I'd like to see what other's feel about this though.
:)
 
I would count it

Doctors don't always dictate in the order in which an auditor wants to check off the bullet points for determining the accurate code.

The "context" for this injury (when he was lifting weights) seems to be something that would have been elicited in taking the history, so I would count it as the 4th element for HPI. By the way you also have Modifying factors in that he stopped gym for 2 months but the pain persisted (but you don't need a 5th element).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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